This proposal is submitted in response to PA-07-119 (Health Services Research on the Prevention and Treatment of Drug and Alcohol Abuse) from NIDA and addresses major gaps in health services research for nicotine addiction treatments for entire populations of smokers and for the 80% who are not motivated to quit. Nicotine addiction is just like other drug addictions in terms of breaking the addiction cycle. This research will be done in collaboration with the Health and Wellness Institute founded for dissemination purposes by Blue Cross of Rhode Island which serves over 70% of the state. Health service researchers and providers differ on whether treatment emphasis should be on clinician-based counseling, biologically-based medications, computer-based tailored communications or a combination of these. There is a lack of comparative research on population treatments to compare effectiveness, cost-effectiveness and enhancement of quality of life. Such comparative research would provide health care systems and providers with evidence on how to best serve entire populations of smokers, especially unmotivated smokers who are seriously underserved. This research will compare the four most highly recommended treatments: 1. Motivation Enhancement Therapy (MET) plus NRT;2. Reduction Therapy plus NRT;3.Tailored communications based on the Transtheoretical Model (TTM), and 4. The combination of these treatments. A five group randomized comparative treatment design will compare MET, Reduction, TTM Tailored and combined treatments and assess multiple outcomes at 0, 6, 12, 18 and 24 months. The study will proactively screen the health care system population to identify a sample of 2,500 smokers, including 2,000 unmotivated smokers. Secondary aims will examine cessation outcome trajectories (No Treatment Effects, Stable Effects after treatment, Decreasing Effects or Increasing Effects), and potential mediators of how the treatments work. PUBLIC HEALTH RELEVANCE: If the treatment combining Motivation Enhancement, Reduction Counseling, Nicotine Replacement Therapy and Transtheoretical tailored interventions produces an increasing treatment trajectory, it will produce unprecedented impacts with unmotivated smokers specifically and population cessation generally. These recruitment and intervention strategies require limited resources from health care providers and could be readily disseminable to other health care systems for application with populations of smokers, especially unmotivated smokers who have been understudied and underserved.